Multiple policy approaches in improving community pharmacy practice: the case in Indonesia.

BACKGROUND: Health reform has been an ongoing agenda in many countries with community pharmacy increasingly gaining attention for contributing to healthcare improvement. Likewise, multiple policy approaches have been introduced to improve community pharmacy practice in Indonesia yet no studies have evaluated their effectiveness. Therefore, this study aimed to identify and collate information on approaches intended to improve practice in Indonesian community pharmacy and subsequently examine the perceptions of key stakeholders in healthcare and community pharmacy about these approaches and the extent to which they have affected community pharmacists as a profession. METHODS: This study reviewed the grey literature related to community pharmacy policies published by government and pharmacy organisations in Indonesia since 2009 and broadened the search to other relevant databases. In-depth semi structured interviews were conducted with a wide range of key stakeholders in pharmacy and healthcare between February and August 2016 to evaluate these policy approaches. RESULTS: Seventeen policy documents were identified with the majority published by the Indonesian Pharmacists' Association (8 documents) and Ministry of Health of Indonesia (6 documents). Most documents (15 documents), either the updated version or new policy, were published since 2014 indicating the recent enthusiasm of pharmacy stakeholders to improve community pharmacy practice. Twenty-nine key stakeholders participated in the study, and highlighted three main themes regarding the policy approaches: barriers to effective policy implementation, need for policy changes and strategies to cope with policy challenges. Poor policy enforcement was commonly expressed by participants as a major challenge, with participants anticipating the need for a unified stakeholder vision to improve the current situation. Participants also mentioned several local initiatives which they claimed were improving practice but evidence was lacking. CONCLUSION: The introduction of policy initiatives within the past ten years has highlighted the enthusiasm of policy makers and pharmacy stakeholders to improve community pharmacy practice in Indonesia. However, some of the initiatives were conceived and enacted in a piecemeal, sometimes conflicting and uncoordinated way. Overall, fundamental and entrenched barriers to practice need to be overcome to create a more professional climate for the practice of pharmacy in Indonesia.

Development and evaluation of an innovative model of inter-professional education focused on asthma medication use.

BACKGROUND: Inter-professional learning has been promoted as the solution to many clinical management issues. One such issue is the correct use of asthma inhaler devices. Up to 80% of people with asthma use their inhaler device incorrectly. The implications of this are poor asthma control and quality of life. Correct inhaler technique can be taught, however these educational instructions need to be repeated if correct technique is to be maintained. It is important to maximise the opportunities to deliver this education in primary care. In light of this, it is important to explore how health care providers, in particular pharmacists and general medical practitioners, can work together in delivering inhaler technique education to patients, over time. Therefore, there is a need to develop and evaluate effective inter-professional education, which will address the need to educate patients in the correct use of their inhalers as well as equip health care professionals with skills to engage in collaborative relationships with each other. METHODS: This mixed methods study involves the development and evaluation of three modules of continuing education, Model 1, Model 2 and Model 3. A fourth group, Model 4, acting as a control.Model 1 consists of face-to-face continuing professional education on asthma inhaler technique, aimed at pharmacists, general medical practitioners and their practice nurses.Model 2 is an electronic online continuing education module based on Model 1 principles.Model 3 is also based on asthma inhaler technique education but employs a learning intervention targeting health care professional relationships and is based on sociocultural theory.This study took the form of a parallel group, repeated measure design. Following the completion of continuing professional education, health care professionals recruited people with asthma and followed them up for 6 months. During this period, inhaler device technique training was delivered and data on patient inhaler technique, clinical and humanistic outcomes were collected. Outcomes related to professional collaborative relationships were also measured. DISCUSSION: Challenges presented included the requirement of significant financial resources for development of study materials and limited availability of validated tools to measure health care professional collaboration over time.

Investigating the impact of the universal healthcare coverage programme on community pharmacy practice.

The introduction of Universal Healthcare Coverage (JKN) in 2014 has changed the landscape of the Indonesian healthcare and affected the community pharmacy sector. This paper investigates perceptions of healthcare and pharmacy stakeholders about the impact of JKN on the practice of pharmacists and pharmacy in both public (Puskesmas) and private (Community or Retail pharmacy) settings. In-depth, semi-structured interviews were conducted from February to August 2016 involving 29 participants representing key stakeholders from different provinces in Indonesia. While JKN was actually designed with good policy objectives for pharmacy integration within primary care network, it has created some unintended and unanticipated distortion in the healthcare system which may be detrimental to the community pharmacy sector. In fact, community pharmacy practice is still limited to dispensing and continued to be hampered by ongoing challenges mainly pharmacists' absence, lack of clinical competence and limited support from regulation changes. It is a missed opportunity for pharmacists to play a greater role in primary care services indicating the need for an overhaul to pharmacy education and policy system.

Prioritising recommendations to advance community pharmacy practice.

INTRODUCTION: The nature of community pharmacy in many countries has changed. Despite the significant efforts made to change practice, there is a paucity of literature that highlights consensus on the approaches that should be prioritised for advancing practice particularly in the context of developing countries. OBJECTIVE: To systematically identify and prioritise a range of potential recommendations to improve practice in Indonesian community pharmacy from the perspective of pharmacy stakeholders. METHODS: Qualitative research using Nominal Group Technique (NGT) was conducted in July 2017 involving 34 nationwide pharmacy stakeholders. Participants were assigned to four nominal group discussions based on the areas for action as developed by researchers. The results were thematically analysed. RESULTS: Nine priority recommendations were generated from the group discussion reflecting four main themes to advance community pharmacy sector, namely improving professional pharmacy practice, reforming pharmacy education, enforcing policy and regulation and enhancing public recognition of pharmacists. The analysis using the culture-structure-agency approach highlights that the top down structure in terms of policy and regulatory framework has not been effectively enforced. In addition, the role of pharmacists as the central agency in delivering pharmacy services has been limited due to their common absence from practice. The approach, however, provides an alternative to advocate changes by locating the role of pharmacists and community pharmacy as central agency within the challenging health system structure. CONCLUSIONS: The recommendations generated from and approach used in this study provide an impetus to advance community pharmacy practice in Indonesia. Amongst the important solutions, there is substantial need to provide evidence of pharmacists' contribution to healthcare.

The operation of a Research and Development (R&D) program and its significance for practice change in community pharmacy.

BACKGROUND: Community pharmacy practice in Australia is changing and Research and Development (R&D) in community pharmacy plays an important role in contributing to the changes. A range of Cognitive Pharmacy Services (CPS) were developed from R&D programs, yet their implementation has been minimal indicating slow practice change within community pharmacy. Given the vital role of R&D, little is known about the operation and the extent to which it has been effective in supporting practice change in community pharmacy. METHODS: In depth, semi-structured interviews were conducted with 27 key stakeholders in the pharmacy and healthcare system in Australia. All interviews were audio-recorded, transcribed ad verbatim and analysed using an inductive approach. RESULTS: Participants perceived that the R&D program has played an important role in the advent of CPS. Furthermore, they considered that evidence generated by the R&D projects is a critical influence on policy formulation, funding and implementation of CPS into practice. However, policy decisions and subsequent implementation are also influenced by other factors associated with context and facilitation which in turn foster or inhibit effective Knowledge Translation (KT) in the community pharmacy sector. CONCLUSION: While R&D programs have been viewed as essential for supporting changes in community pharmacy practice through development and funding of CPS, the overall impact has been small, as contemporary practice continues to be predominantly a dispensing model. Given the complexity and dynamic nature of the community pharmacy system, stakeholders must take into account the inter-relationship between context, evidence and facilitation for successful KT in community pharmacy practice.

Investigating influences on current community pharmacy practice at micro, meso, and macro levels.

BACKGROUND: The nature of Australian community pharmacy is continually evolving, raising the need to explore the current situation in order to understand the potential impact of any changes. Although community pharmacy has the potential to play a greater role in health care, it is currently not meeting this potential. OBJECTIVE: To investigate the nature of the contemporary practice of community pharmacy in Australia and examine the potential missed opportunities for role expansion in health care. METHODS: In-depth semi-structured interviews with a wide-range of key stakeholders within and beyond community pharmacy circles were conducted. Interviews were audio-recorded, transcribed verbatim and analyzed for emerging themes. RESULTS: Twenty-seven key informants across Eastern half of Australia were interviewed between December 2014 and August 2015. Several key elements of the current situation representing the social, economic and policy context of community pharmacy have been identified. These elements operate interdependently, influence micro, meso and macro levels of community pharmacy operation and are changing in the current climate. Community pharmacy has untapped potential in primary health care, but it has been slow to change to meet opportunities available in the current situation. CONCLUSIONS: As the current situation is complex, interrelated and dynamic with often unintended and unpredictable consequences, this paper suggests that policy makers to consider the micro, meso and macro levels of community pharmacy operation when making significant policy changes. The framework proposed in this study can be a helpful tool to analyze the processes operating at these three levels and their influences on practice.

Community pharmacy and emerging public health initiatives in developing Southeast Asian countries: a systematic review.

The development of health and healthcare systems in South-East Asia has influenced the practice of community pharmacy. Over the years, community pharmacy in the region has striven to expand services beyond dispensing to encompass more involvement in public health issues. Searches were conducted in Scopus, EMBASE, MEDLINE and PubMed for articles published between January 2000 and December 2014, with 21 studies in five countries meeting the inclusion criteria. The findings showed increasing interest in research into the delivery of pharmacy services and public health initiatives. Overall, the review found that provision of some health services in pharmacies was common; however, most public health initiatives appeared to be poorly implemented, had limited evidence and were not demonstrated to be sustainable across the sector. This indicates that the practice of community pharmacy in the region has not significantly changed over the past 14 years with respect to the scope and quality of pharmacy services provided, and fundamental policy changes are necessary to improve this situation.

An international comparison study of pharmacy students' achievement goals and their relationship to assessment type and scores.

OBJECTIVE: To identify pharmacy students' preferred achievement goals in a multi-national undergraduate population, to investigate achievement goal preferences across comparable degree programs, and to identify relationships between achievement goals, academic performance, and assessment type. METHODS: The Achievement Goal Questionnaire was administered to second year students in 4 universities in Australia, New Zealand, England, and Wales. Academic performance was measured using total scores, multiple-choice questions, and written answers (short essay). RESULTS: Four hundred eighty-six second year students participated. Students showed an overall preference for the mastery-approach goal orientation across all sites. The predicted relationships between goal orientation and multiple-choice questions, and written answers scores, were significant. CONCLUSION: This study is the first of its kind to examine pharmacy students' achievement goals at a multi-national level and to differentiate between assessment type and measures of achievement motivation. Students adopting a mastery-approach goal are more likely to gain high scores in assessments that measure understanding and depth of knowledge.

Identifying achievement goals and their relationship to academic achievement in undergraduate pharmacy students.

OBJECTIVES: To compare the achievement goal orientations of first-year with those of third-year undergraduate Australian pharmacy students and to examine the relationship of goal orientations to academic achievement. METHODS: The Achievement Goal Questionnaire was administered to first-year and third-year students during class time. Students' grades were obtained from course coordinators. RESULTS: More first-year students adopted performance-approach and mastery-approach goals than did third-year students. Performance-approach goals were positively correlated with academic achievement in the first year. Chinese Australian students scored the highest in adopting performance-approach goals. Vietnamese Australian students adopted mastery-avoidance goals more than other ethnicities. First-year students were more strongly performance approach goal-oriented than third-year students. CONCLUSION: Adopting performance-approach goals was positively correlated with academic achievement, while adopting avoidance goals was not. Ethnicity has an effect on the adoption of achievement goals and academic achievement.

Investigating the relationship between pharmacy students' achievement goal orientations and preferred teacher qualities.

OBJECTIVE: To investigate the relationships between pharmacy students' preferred teacher qualities and their academic achievement goal orientations. METHODS: Participants completed an achievement goal questionnaire and a build-a-teacher task. For the latter, students were given a $20 hypothetical budget to purchase amounts of 9 widely valued teachers' qualities. RESULTS: Three hundred sixty-six students participated. Students spent most of their budget on the traits of enthusiasm, expertise, and clear presentation style, and the least amount of money on interactive teaching, reasonable workload, warm personality, and intellectually challenging. In relation to achievement goals, negative associations were found between avoidance goals and preferences for teachers who encourage rigorous thinking and self-direction. CONCLUSION: These novel findings provide a richer profile of the ways students respond to their learning environment. Understanding the relationships between teachers' characteristics and pharmacy students' achievement goal orientations will contribute to improving the quality of pharmacy learning and teaching environments.

An international validation study of two achievement goal measures in a pharmacy education context.

BACKGROUND: Achievement goal theory helps us understand what motivates students to participate in educational activities. However, measuring achievement goals in a precise manner is problematic. Elliot and McGregor's Achievement Goal Questionnaire (AGQ) and Elliot and Murayama's revised Achievement Goal Questionnaire (AGQ-R) are widely used to assess students' achievement goals. Both instruments were developed and validated using undergraduate psychology students in the USA. METHODS: In this study, our aims were to first of all, assess the construct validity of both questionnaires using a cohort of Australian pharmacy students and, subsequently, to test the generalizability and replicability of these tools more widely in schools of pharmacy in other English-speaking countries. The AGQ and the AGQ-R were administered during tutorial class time. Confirmatory factor analysis procedures, using AMOS 19 software, were performed to determine model fit. RESULTS: In contrast to the scale developers' findings, confirmatory factor analysis supported a superior model fit for the AGQ compared with the AGQ-R, in all countries under study. CONCLUSION: Validating measures of achievement goal motivation for use in pharmacy education is necessary and has implications for future research. Based on these results, the AGQ will be used to conduct future cross-sectional and longitudinal analyses of the achievement goals of undergraduate pharmacy students from these countries.

Fitness to practise in pharmacy: a study of impairment in professional practice.

OBJECTIVE: To explore the opinions and knowledge of Australian pharmacists about impairment in the profession, and their awareness of new legislation regarding impairment and mandatory reporting. SETTING: Pharmacy practice in Australia. METHOD: Pharmacists' opinions and knowledge were explored using a purposively designed, de-identified survey distributed by an intermediate mailing house to randomly selected pharmacists registered with the Pharmacy Board. Descriptive statistics and thematic analyses were conducted on the data. KEY OUTCOME MEASURES: This being an explorative study, we analysed various items using standard statistical methods and qualitative thematic analysis for responses to open-ended questions. RESULTS: Responses from 370 registered pharmacists were obtained. Of these, nearly 60% were not confident in their knowledge of legislation relating to impairment. The vast majority stated they would consider reporting an impaired colleague in principle, but only after consulting the colleague. Older pharmacists demonstrated increased awareness of new legislation; this was accompanied however, by a marked decrease in confidence regarding knowledge about impairment. Thematic analysis of the qualitative data revealed four main themes: (1) perception of impairment and support systems available (2) stigma related to implications of impairment and whistle-blowing (3) factors affecting reporting of impairment and (4) management of impairment. CONCLUSION: Australian pharmacists in this study recognised the importance of the issue of impairment, but appeared to lack confidence and/or awareness of legislative requirements regarding impairment in the profession. There is a need for educative programs and accessible, profession-specific rehabilitative programs to be instigated for management of impairment in the profession of pharmacy in Australia.

Pharmacy students' approaches to learning in undergraduate and graduate entry programs.

OBJECTIVES: To compare longitudinal data with previous cross-sectional data regarding Australian undergraduate pharmacy students' approaches to learning, and explore the differences in approaches to learning between undergraduate and postgraduate cohorts. METHODS: Longitudinal, repeated measures design using a validated self-report survey instrument were used to gather data. RESULTS: Undergraduate students' preferences for meaning directed, undirected, and reproduction-directed approaches to learning displayed the same pattern across the 2 studies; however, application-directed scores increased significantly in the second half of the undergraduate degree program. Commencing postgraduate students' approaches to learning were similar to finishing undergraduate students, and this group was significantly more oriented towards meaning-directed learning compared to undergraduate students. CONCLUSIONS: Pharmacy students' maturation in approach to their learning was evident and this bodes well for pharmacists' engaging in life-long learning and capacity to work in increasingly complex health settings.

Best practices assessment to guide curricular change in a bachelor of pharmacy program.

OBJECTIVES: To identify best practices in global pharmacy education and curriculum design as the basis for decisions about major curriculum change in an existing 4-year bachelor of pharmacy curriculum. DESIGN: We investigated international best-practice standards, conducted semi-structured interviews with faculty members, and used standardized instruments to investigate student perceptions of the existing curriculum and how they approached their learning. ASSESSMENT: Faculty recommendations included horizontal and vertical integration of curriculum content to replace the previous discipline-based approach; and a theme-based structure underpinned by a detailed statement of learning outcomes that describe the knowledge, skills, and attitudinal milestones to be achieved each year and by the time of graduation. The triangulation of student survey data highlighted issues that needed to be addressed at the individual course unit level, with a particular focus on feedback, assessment, and workload. CONCLUSIONS: The results of the curriculum review provided clear guidance for decisions relating to major curriculum change. An ongoing program of staff development will address the wide range of learning and teaching issues identified by both staff members and students. The results of our investigation of students' approaches to learning will also be used to guide staff development workshops, focusing on strategies to promote "meaningful learning."

Pharmacy students' approaches to learning in an Australian university.

OBJECTIVES: To investigate how pharmacy students' approaches to learning change over the duration of a bachelor of pharmacy degree program. METHODS: Data were obtained from a cross-sectional, repeated measures design, using a validated self-report survey instrument. Areas examined included processing and regulation strategies, motivational preferences for learning, and the relationship between approaches to learning and academic performance. RESULTS: Pharmacy students were strongly vocationally oriented in their studies across all year groups. This approach had a significant relationship to academic performance. Overall, students indicated a preference for external regulation strategies. There was little evidence of maturation in approaches to learning as students progressed through the curriculum. CONCLUSIONS: Students' preference for vocationally related strategies can be harnessed to increase both adoption of self-regulation behaviors and motivation for mastery of material. Comparison of our results with other studies indicates that approaches to learning may be influenced more by the learning environment than the discipline of study.